In Vitro Fertilization (IVF)

Tubal Reversal vs. IVF

One of the frequently asked questions in fertility care is whether a woman who wants to have babies after a tubal ligation should have a tubal reversal surgery or should go straight into in vitro fertilization (IVF). While there is no uniform, and simple, answer to this question, the trend has been away from surgery and towards IVF. And there are good reasons for this trend, both medical and economic.

A tubal ligation, in principle, involves the surgical interruption of both fallopian tubes. Since intact tubes are essential for egg and sperm to meet, and for fertilization to occur, their surgical interruption of the tubes prevents pregnancy.

Tubal ligations can be performed in two ways: either a portion of the tube is coagulated (i.e., burned), or a portion of the tube is simply excised (cut). The technique utilized is important because the success of tubal reversal surgery greatly depends on how much healthy tube was left after the initial tubal ligation. If not enough was left, good surgeons will not even attempt a reversal, since a tubal reversal surgery will not lead to a successful pregnancy.

Unfortunately, it is not always possible to determine whether enough healthy tube is left before a surgery and it, therefore, is not uncommon that patients go into surgery under the assumption that they will have a tubal reversal surgery done, only to wake up from anesthesia to be told that there wasn't enough tube left to even try.

Length of remaining tube is not the only decisive factor; the remaining tube's quality also counts. And here, the kind of tubal ligation that was performed once again comes into play. If the tubes were "burned," heat damage to tubal tissues can be very extensive and reach far beyond visible areas. Tubal ligations by coagulation are rarely good candidates for reversal surgery.

There other other forms of tubal sterilization, such as the so-called distal salpingectomy or fimbriectomy and complete salpingectomy. In these two forms of tubal sterilization either the distal portion of the tube (the fimbriae) or the entire tube are removed. These two sterilization procedures never lend themselves to reversal.

How to Choose between Tubal Reversal & IVF

Much of what we discussed above will determine the choice between tubal reversal surgery and IVF. Clearly, if the tubal ligation was done by coagulation, or if it was either a fimbriectomy or salpingectomy, the choice will be IVF. What, however, if your tubal ligation was done by straight forward knife (scalpel) excision?

Under such a circumstance, the medical decision can go either way, provided you can be certain that the surgeon left enough length of the tubes to allow for a proper reversal surgery. How can you be certain? Your (and your physician) really never can, until the surgeon holds the two ends of the tube in his/her hands at time of surgery. However, one can make an educated guess: First, it is important to review the operative report from the tubal ligation surgery. Properly executed reports should indicate how much tube was left after the surgery was completed. In addition, a
hysterosalpingogram (HSG)hysterosalpingogram (HSG)
can be performed. HSG is an x-ra procedure, in which the proximal part of the remaining fallopian tubes (i.e., the part closer to the uterus, and before the surgical interruption) can be outlined. Confirming that this part is of adequate length does not guarantee that the distal part (the part after the interruption) is adequate, but makes it more likely.

Tubal reversal surgeries are pursued with the assumption that the remaining tubes are, with great likelihood, adequate. However, a final judgment as to whether the surgery is technically feasible is not possible until the surgeon directly visualizes your tubes during surgery. By that time you would already be under anesthesia. This is a big argument against tubal reversal surgery and for IVF.

Advantages & Disadvantages

Going the tubal reversal surgery route has one overwhelming advantage: if successful, tubal reversal surgery does not require any follow up treatments. You and your partner return to the standard way of having babies, and, hopefully, also have a lot of fun doing so.

Tubal reversal surgery has, however, also a number of risks and disadvantages compared to the alternative of IVF. The first disadvantage we already discussed: the surgery may simply turn out to be technically unfeasible. A very important second disadvantage is that, even if the surgery is performed well, on the average, only approximately 50-75% (depending which reports you believe) of fallopian tubes remain open after surgery, and reported pregnancy rates usually are in approximately the 50% range.

And, finally, surgery is always expensive because it usually involves operating rooms in hospitals (or surgicenters), in addition to physician fees, and both of those are usually quite costly. Medical insurances usually do not cover voluntary tubal reversals, either.

Other important considerations include whether you and your partner would need other medical interventions, like IVF, to conceive, even after a successful tubal reversal surgery. For example, if you had a tubal ligation 20 years ago and you are now wanting to have another baby at age 42, chances are, even with open tubes, you may end up needing IVF due to age-related diminished ovarian reserve. These factors should be taken into account when choosing between tubal reversal surgery and IVF.